Provider Demographics
NPI:1114331139
Name:COUNTY OF LOS ANGELES DEPARTMENT OF MENTAL HEALTH
Entity Type:Organization
Organization Name:COUNTY OF LOS ANGELES DEPARTMENT OF MENTAL HEALTH
Other - Org Name:CENTRAL JUVENILE HALL MENTAL HEALTH UNIT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SOUTHARD, D.S.W.
Authorized Official - Suffix:
Authorized Official - Credentials:DSW
Authorized Official - Phone:213-738-4601
Mailing Address - Street 1:1605 EASTLAKE AVENUE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033
Mailing Address - Country:US
Mailing Address - Phone:323-226-8826
Mailing Address - Fax:323-226-8820
Practice Address - Street 1:1605 EASTLAKE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1009
Practice Address - Country:US
Practice Address - Phone:323-226-8826
Practice Address - Fax:323-226-8820
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF LOS ANGELES DEPARTMENT OF MENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service